moderate“Some care calls had continued to be cancelled at short notice, relying on relative to provide support, and this was an area for improvement.”
critical“People's calls were late or had been cancelled at short notice, relying on people's families to support their loved ones.”
staffing levels
2 findings
moderate“The service was reliant on agency carers to cover staff sickness and was actively recruiting to increase their staff levels.”
critical“The provider failed to ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons were deployed to meet people's needs.”
governance
2 findings
moderate“Some of these had been introduced in March, were now being completed and needed time to be embedded in day-to-day practice.”
critical“The provider failed to ensure systems and processes were established and operated effectively to assess, monitor and improve the quality and safety of the services provided.”
leadership
2 findings
moderate“At the time of our inspection there was not a registered manager in post. An application had been received by CQC for a manager to register.”
critical“The service had not had a registered manager leading the service since September 2021. There had been several changes in manager.”
complaints handling
1 finding
moderate“One person told us they had raised a complaint at the end of 2022, and it had not been investigated.”
safeguarding
1 finding
critical“The provider's failure to provide sufficient numbers of staff, to ensure people received their support in a safe and timely way, represented neglect, a form of abuse.”
medication management
1 finding
critical“There was a risk people may not be supported to have their medicines as prescribed as many care calls were late or cancelled.”
care planning
1 finding
moderate“Care plans lacked important information about people's health conditions. Care plans varied in the level of person-centred detail.”
staff competency
1 finding
moderate“Staff completed medicines administration training. However, staff competency had not been assessed to ensure they followed best practice.”
incident learning
1 finding
moderate“The manager had not completed any analysis of the missed or cancelled calls. People had raised concerns with the office about their calls being late.”
supervision appraisal
1 finding
moderate“The manager had not completed any staff competency assessments or audits of care plans or medicines management since they started at the service.”
record keeping
1 finding
minor“When people had prescribed creams to help keep their skin healthy, there were no topical body maps to guide staff to where the creams should be applied.”